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Outline for a talk given by Roger Litten at the College of Psychoanalysts-UK International Conference PSYCHOANALYSIS AND STATE REGULATION, 31 March-1 April 2006

We are faced with a move towards the state regulation
Of what are called talking therapies in this country
The question is how to oppose it

The most obvious difficulty
Is the apparent self-evidence of the need for regulation
The need for qualifications and standards to counter
The risk to the public posed by unqualified or incompetent practitioners

This makes it difficult to even raise the question
Why we need regulation of these forms of therapy
Especially when the call for regulation is supported by
The majority of professional bodies themselves

The debate in this country already seems to have moved beyond
Question of why, of whether regulation is necessary
To the pragmatic details of how to be regulated
Losing sight of any basis for attempts to oppose principle of regulation itself

In order to find ways to effectively oppose regulation
Thus need in the first instance to find ways to bring
The apparent self-evidence of the need for regulation back into question

I would like to suggest that the most effective way of doing this is to
Examine the relation between the why and the how of regulation
Introduce questions like well why now, why like this
Make visible logic at stake in move towards regulation
That will allow us to identify possible basis for effective opposition

I would like to start with a distinction
between what we might call the rationale and the logic of regulation
I propose to examine the common rationale of the call for regulation
In an attempt to demonstrate that there is an alternative logic at stake

I want to focus on the articulation between the current discourse of regulation
and a more complex and insidious discourse of evaluation, accountability, audit
I will suggest that it is this discourse of evaluation and audit
That lies behind the government's push towards state regulation of the talking therapies
And that must be exposed as the hidden stake of the discourse of regulation

We start at the level of the accepted rationale for regulation
Which can be summed up in the common refrain of
The need for public protection
And the maintenance of standards of practice

I would suggest that already here in the two elements of this refrain
That has become so familiar that we barely question the self-evidence
Of the association between public protection and the maintenance of standards.
We have the nuclear articulation between regulation and evaluation

I would like to follow through this rationale for regulation
To the point where this discourse articulates with the question of evaluation
In order to expose the alternative logic at stake and the contradictions entailed

By following this approach I hope we can arrive at the point where it becomes possible
To demonstrate that not only does regulation not achieve what it claims to set out to achieve
Ie does not do what it says on the tin
But also entails consequences and effects
That just happen to be the very opposite of what it claims

In other words we set out from a rationale for regulation
Elaborated on the basis of a discourse of public protection
Only to stumble into a system of audit and accountability
That at certain points can be seen to provide no protection at all
To the very people it claims to serve

In this way hope to be able to elaborate
a symptomatic and diagnostic reading of the discourse of regulation
That will provide the basis for effective opposition to that discourse
By elaborating a psychoanalytic critique of the logic at stake

I have suggested that it is the apparent self-evidence of the rationale for regulation
That makes it so difficult to challenge,
To even raise the question of why we need regulation

This difficulty getting a hearing for the question why
Should not in the first instance prevent us introducing questions
Such as well why now and why like this?
The prospect of regulation of the psychotherapies has been on horizon for decades
Yet it is only now that the government seems to have built up a head of steam to push it through
We will thus start with the question why now in order to return to the question why at all

There are at least two possible answers to the question why now
One is extremely localised and the other more complex and diffuse
If you will allow me I hope to be able to trace out a relation between them
In order to provide the framework for a critical examination of the apparatus of regulation
Outlined in current proposals for the regulation of the talking therapies by the HPC

In the first instance I think it would be a mistake to lose sight of the fact that
This programme of regulation is not aimed at psychoanalysis in particular
Nor even necessarily at the talking therapies in general
But is rather part of a broader programme of governmental regulation
Being unrolled on various fronts in security, education and health
And which is only now being extended into the sphere of the 'talking therapies'
Which will by implication include psychoanalysis at one level or another

Suggest that this makes it all the more difficult for us to oppose
But at the same time even more imperative for us to do so
Because if psychoanalysis is not able to mount a critique of these proposals
Then who can we expect to do so on our behalf?

Have suggested that there are two possible answers to question why now
I will start with the most localised answer,
which can go under the name of Dr. Harold Shipman
The doctor who murdered all his patients for no apparent reason
Apart from the fact that he seemed to enjoy doing it, was addicted to killing

We can use this singular instance of the flagrant betrayal
of everything the figure of the doctor is supposed to stand for
to mark a point of breakdown in the traditional relation between patient and doctor
The loss of trust in the figure of medical authority
Accompanied by a loss of confidence in the profession as a whole

The impact of the Shipman case
Must of course be situated in relation to other contemporary medical scandals
Alder Hey, the Bristol enquiry,
Cases of medical negligence and incompetence
That appear to have continued undetected for years

These have raised justified questions about the ability of the GMC,
The body representing medical authority and professional self regulation,
To safeguard the public from malpractice by its own members
The failure of the professional body to ensure public protection
And maintenance of standards of practice within the medical profession
Then leaves the door open to a demand for State intervention

These scandals thus mark a point of erosion of the autonomy of professional bodies
The rise of calls for external monitoring and independent enquiries
For the removal of the regulatory role of a professional body
seen to have failed in its responsibilities to the public
to be replaced by a system of regulation by independent bodies
that would be independent, transparent, and accountable to the State

I am using this example of the position of
one of the more influential professional bodies in the UK
as the quickest way to sketch the shift
away from a culture of professional self-regulation in this country
Towards a culture of accountability and State regulation

I am aware that this is a very rapid sketch, taking a number of shortcuts,
In what is in itself a highly complex problematic
I am attempting only to situate the most general framework of this shift
In order to go on to identify pressure points in the argument for regulation
Hoping to demonstrate that we can use a common logic of analysis at each point

The perceived failure of the system of self-regulation by professional organisations
Their failure to safeguard their position of responsibility and medical authority
Coincides with a breakdown in relation of trust between patient and doctor
And ultimately with a loss of confidence in the profession as a whole

This opens the door of the clinic to the intervention of an independent third party
Assumes an external point of arbitration in the name of transparency and accountability
Able to hear complaints from patients and to respond to them
And ultimately to judge on adequacy of professional practice

This shift in the external legal and statutory framework of professional practice
Then entails profound modifications,
some of which have already been outlined in Christopher Bollas' work on confidentiality,
for the internal dynamics of a psychoanalytic clinic founded on
the privileging of the transferential relation between patient and analyst

Here I only want to sketch in
Framework of this shift from responsibility to accountability
As basis of rationale for introducing an independent State regulator
As the background to the introduction of the Health Professionals Council
Regulatory body for health professions supplementary to medicine

In first instance the HPC appears no more than glorified complaints body
With a remit to hear complaints laid by members of the public against practitioners
And to provide independent judgement of legitimacy of those complaints
Together with statutory powers to enforce sanctions in appropriate cases

It is of course possible to trace in detail
The subtle and progressive extension of this remit on a number of fronts
From hearing complaints, to judging fitness to practice,
To the issuing or with-holding of licence to practice
To the vetting of qualifications and accreditation of training courses,
To having a say not just in the curricula of those training courses
But also in the criteria according to which trainees are selected

All of this in the name of protecting the public
By maintaining standards of practice and training

Here I wish to highlight just one aspect of HPC's work
Its responsibility for drawing up standard Codes of Ethics and Practice
That will be binding for each profession under its remit

Clear that for an external body to hear complaints
against practitioners from a wide range of professions
It will need objective standards against which competence can be judged
This is one way of understanding the increased importance
Being given to Codes of Professional Practice
Objective standards of practice to which members of a profession adhere

These standards of practice made available to clients
And form the basis for deciding whether there are valid grounds for complaint
As well as the basis for judgement by HPC whether that complaint is legitimate
Whether there has been a failure to meet standards of practice as laid out in that code

The judgement of the adequacy of practice, or the legitimacy of a complaint
Thus comes to be reduced to the question of whether
The stated codes of practice have been breached or not

We thus find codes of ethics and practice effectively reduced to a customer charter
A psychoanalyst or psychotherapist provides a service
No different from a plumber or a mechanic
That requires protection of customer rights with a service guarantee
Complaints procedures and refunds if not fully satisfied
and recourse to an independent regulatory body if something goes wrong

This is perhaps a slightly facetious way of approaching
what is undoubtedly a complex and serious question
But once again we find ourselves drawn into a culture in which
The need for Codes of Practice becomes so widely accepted and so self evident
that it becomes difficult to critically examine what is involved

Without diminishing the importance of this question
We would need to examine role played by contemporary codes of practice
Within the framework of the shift from a discourse of responsibility to one of accountability
From a conception of ethics and responsibility
internal to the relation between patient and practitioner
To a notion of accountability as a form of recourse to an independent court of appeal
the introduction of a site for independent third party judgement of the adequacy of practice
made possible on basis of the standards of practice defined by those very codes

This would be one way of examining changes
in the vocabulary, content and role of these codes
The proliferation of codes of practice and ethics within the profession of psychotherapy
Increasingly comprehensive attempt to provide for every possible ethical dilemma or scenario
Provide guideline how to proceed when faced with various ethical dilemmas
Fill the gaps of every possible source of risk with a guarantee

Could suggest that at root all these codes
are designed to safeguard relation between patient and practitioner
In first instance safeguard rights of patients, protect patients from practitioners
But also ultimately for protection of practitioners too
Everyone knows where they stand

Want to question what is at stake in this rationale
Suggest that this very proliferation of codes designed to safeguard that relation
Could be read as a sign of difficulties posed by the nature of that relation itself

Suggest that this understanding of the ethics of relationship between analyst and analysand
This reduction of relation of transference
to commercial contract between service provider and consumer
entails a commodification and objectification of what is at stake in that relationship

These attempts to give positive form to the ethics of that relationship
Would require far more detailed examination than is possible here
because this is precisely one of the major points at which
responsibility is seen to articulate with accountability

But also point at which this shift of framework
Has the effect of skewing the basis of the very relation it seeks to safeguard
Point at which attempts to safeguard that relation in this manner
Slide towards a complete perversion of that relation
That in the end provides no protection or safeguard at all

Again this is a slightly hasty approach to what is fundamental question
Would need to be approached in detail via psychoanalytic theory of transference
Examining rise of notion of the Therapeutic Alliance in contemporary psychotherapy
Understanding of nature of that relation as the basis for psychotherapeutic treatment

Clear that this foregrounding of notion of therapeutic alliance
Underlies the notion of the therapeutic relation as a contract between equal partners
Contract agreed at the start of treatment to lead towards agreed ends

Point at which customer charter notion of the therapeutic contract
Involves complete misunderstanding of what is at stake in transferential relation
And hence basis for any possible therapeutic efficacy of psychoanalytic work in general

But also point at which entails profound and subtle slide towards
Abdication of responsibility for the psychoanalytic position
In favour of an external guarantee of false accountability

Suggest that subscription to culture of accountability
As filtered through discourse of codes of practice
In fact involves increasing abdication of professional responsibility

Not only lose sight of subjective ethics of analytic relation
The true source of analytic responsibility
And in end the only guarantee of psychoanalytic efficacy

But also amounts to a profound betrayal
of source of effectiveness of psychoanalytic work
Culture of accountability left protecting empty shell of psychoanalytic relation
With an external apparatus of contract and guarantee

Point at which we would have to question
whether it is not the psychoanalytic organisations themselves
That have lost sight of this question
Explain not only vulnerability to demands of regulation
Silence in face of these developments
But also their eagerness to comply with the State's wishes
To mask their own difficulties at this point

Ipnosis is edited, maintained and © Denis Postle 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006

August 11 2006
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